Mortality following nursing home-acquired lower respiratory infection: LRI severity, antibiotic treatment, and water intake

ObjectiveIn some nursing home populations, antibiotic treatment may not reduce mortality following lower respiratory infection (LRI). To better inform treatment decisions, we determined influences on mortality following LRI among antibiotic-treated and non–antibiotic-treated residents in 2 populations.DesignObservational, prospective, cohort studies.SettingNinety-seven nursing homes (36 US, 61 Netherlands).ParticipantsResidents (1044 US, 513 Netherlands) who met a standardized study definition for LRI.MeasurementsDemographics, symptoms and physical findings of LRI, functional status, major illness diagnoses, dementia status, treatments, and date of death within 6 months after diagnosis.MethodsWe estimated a 2-period (0–14/15–90 days) weighted proportional hazards model of mortality for antibiotic-treated (n = 1280) and non–antibiotic-treated (n = 277) residents; both weights and regressors provide “doubly robust” risk adjustment—for LRI (illness) severity using a prognostic score and for nonrandom receipt of antibiotic treatment using a propensity score.ResultsIn both the United States and the Netherlands, 14-day mortality was associated with three factors—LRI severity, water intake at diagnosis, and antibiotic use (not directly by severe dementia)—that accounted for 82% or, sequentially, 39%, 42%, and 1% of the cross-national mortality difference. The LRI Severity Score (based only on at-diagnosis eating dependency, pulse rate, decreased alertness, and breathing difficulty, with adequate discrimination [c ≥ 0.74] and calibration, and cross-indexed to commonly used LRI mortality measures) was related to mortality through 90 days, regardless of treatment. With sufficient water intake at diagnosis, 14-day mortality was unrelated to not receiving antibiotic treatment (adjusted hazard ratio [AHR], 1.20; 95% confidence interval, 0.70–2.04); insufficient water intake was related to increased 14-day mortality with antibiotics (AHR, 1.90; 1.38–2.60) or without (AHR, 7.12; 4.83–10.5). After 14 days, relative mortality worsened for antibiotic-treated residents with insufficient water intake. Inadequate water intake was related to increased eating dependence at onset of the LRI (OR, 4.2; 3.0–5.8).ConclusionLRI severity, water intake, and antibiotic use explain mortality in both studies and reconcile cross-study Dutch/US 14-day mortality differences. LRI severity, derived at 14 days, is related to mortality through 90 days, regardless of treatment, and is key to risk adjustment. With adequate hydration, the survival benefit from antibiotic use is nonsignificant. Conversely, hydration, even without antibiotic treatment, appears central to curative treatment. In LRI guidelines, treatment, and research, the relative benefits of antibiotics and hydration for curative treatment should be addressed.     

Risk factors for mortality from lower respiratory infections in nursing home patients.

BACKGROUND. Little is known about the factors that predict whether nursing home residents with lower respiratory infection (LRI) will do well or poorly, although this information is critically important when making treatment decisions. METHODS. Using nursing home and hospital medical records, we performed a case-control study to identify risk factors for death from LRI among residents of a 110-bed, midwestern community nursing home. Three experienced geriatricians aided in the development of an operational definition of an LRI. In a 3 1/2-year period, we identified 26 cases in which the patients died from LRI and 66 control episodes in which the patients recovered from LRI. RESULTS. Compared with those who survived, those who died were 14 times more likely to be totally dependent with respect to activities of daily living (ADL) than the group of patients least ALD-dependent (odds ratio [OR] = 14; 95% confidence interval [95% CI] = 2.85 to 68.87). After adjusting for ADL, mortality was significantly decreased when a broad-spectrum oral antibiotic (trimethoprim-sulfamethoxazole, cefaclor, amoxicillin-clavulanate, or ciprofloxacin) was used as the initial therapy (OR = .14; 95% CI = .02 to .81). CONCLUSIONS. Better functional status and initial therapy with broad-spectrum oral antibiotics were strong predictors of surviving an LRI in this population of nursing home patients. The antibiotic effect may be a treatment effect or the consequence of underlying factors leading physicians to select particular antibiotics; however, it appears possible to identify low-risk persons who do not require the aggressive treatment and hospitalization that is often recommended for these patients. An approach to the treatment of nursing home LRI is suggested.     

Do Patients in Dutch Nursing Homes Have More Pressure Ulcers Than Patients in German Nursing Homes? A Prospective Multicenter Cohort Study

ObjectivesTo investigate whether the incidence of pressure ulcers in nursing homes in the Netherlands and Germany differs and, if so, to identify resident-related risk factors, nursing-related interventions, and structural factors associated with pressure ulcer development in nursing home residents.DesignA prospective multicenter cohort study.SettingTen nursing homes in the Netherlands and 11 nursing homes in Germany (around Berlin and Brandenburg).ParticipantsA total of 547 newly admitted nursing home residents, of which 240 were Dutch and 307 were German. Residents had an expected length of stay of 12 weeks or longer.MeasurementsData were collected for each resident over a 12-week period and included resident characteristics (eg, demographics, medical history, Braden scale scores, nutritional factors), pressure ulcer prevention and treatment characteristics, staffing ratios and other structural nursing home characteristics, and outcome (pressure ulcer development during the study). Data were obtained by trained research assistants.ResultsA significantly higher pressure ulcer incidence rate was found for the Dutch nursing homes (33.3%) compared with the German nursing homes (14.3%). Six factors that explain the difference in pressure ulcer incidence rates were identified: dementia, analgesics use, the use of transfer aids, repositioning the residents, the availability of a tissue viability nurse on the ward, and regular internal quality controls in the nursing home.ConclusionThe pressure ulcer incidence was significantly higher in Dutch nursing homes than in German nursing homes. Factors related to residents, nursing care and structure explain this difference in incidence rates. Continuous attention to pressure ulcer care is important for all health care settings and countries, but Dutch nursing homes especially should pay more attention to repositioning residents, the necessity and correct use of transfer aids, the necessity of analgesics use, the tasks of the tissue viability nurse, and the performance of regular internal quality controls.     

A literature review of clinical outcomes associated with antipsychotic medication use in North American nursing home residents

The benefits and harms of antipsychotic medication (APM) use in nursing home residents need to be examined because, although commonly used, APMs are considered an off-label use by the Food and Drug Administration for residents with dementia and behavioral problems. The objective of this study was to provide a realist literature review, summarizing original research studies on the clinical effects of conventional and atypical APM use in nursing home residents. Searches of multiple databases identified 424 potentially relevant research articles, of which 25 met the inclusion criteria. Antipsychotic medication use in nursing home residents was found to have variable efficacy when used off-label with an increased risk of many adverse events, including mortality, hip fractures, thrombotic events, cardiovascular events and hospitalizations. Findings suggested certain APM dosing regimens (e.g. fixed-dose) and shorter duration of use might have fewer adverse events. Non-pharmacological interventions should still be considered the first-line treatment option for nursing home residents with dementia related behavioral disturbances, as more studies are needed to establish safer criteria for APM use in nursing homes residents.     

Antibiotics and mortality in patients with lower respiratory infection and advanced dementia

ObjectivesTo describe long-term mortality rate and to assess associations between mortality rate and antibiotic treatment of lower respiratory infection in patients with advanced dementia; antibiotic treatment allocation was independent of mortality risk—leaving less room for biased associations than in previous multicenter observational studies.DesignProspective study (2004–2009). Multilevel Cox proportional hazard analyses with adjustment for mortality risk were used to assess associations between antibiotics and mortality using time-dependent covariates.SettingA US Department of Veterans Affairs nursing home.ParticipantsNinety-four residents with advanced dementia who developed 109 episodes.MeasurementsSurvival, treatment, mortality risk, illness severity, fluid intake, and several other patient characteristics.ResultsTen-day mortality was 48%, and 6-month mortality was 74%. Antibiotics were used in 77% of episodes. Overall, antibiotics were not associated with mortality rate (Hazard Ratio [HR] 0.70, Confidence Interval [CI] 0.38–1.30); however, antibiotics were associated with reduced 10-day mortality rate (HR 0.51, CI, 0.30–0.87; rate after 10 days: 1.5, CI 0.42–5.2). Benefit from antibiotics was less likely with inadequate fluid intake, and when experiencing the first episode.ConclusionIn our sample of male nursing home residents with advanced dementia and lower respiratory infection, mortality was substantial despite antibiotic treatment. Antibiotics prolonged life but in many cases only for several days. Treatment decisions should take into account that antibiotics may delay death but may also prolong the dying process, indicating a need for accurate prediction of mortality and study of characteristics that may alter effectiveness of antibiotics.     

Soundscape Awareness Intervention Reduced Neuropsychiatric Symptoms in Nursing Home Residents With Dementia: A Cluster-Randomized Trial With MoSART+

ObjectivesAuditory environments as perceived by an individual, also called soundscapes, are often suboptimal for nursing home residents. Poor soundscapes have been associated with neuropsychiatric symptoms (NPS). We evaluated the effect of the Mobile Soundscape Appraisal and Recording Technology sound awareness intervention (MoSART+) on NPS in nursing home residents with dementia.DesignA 15-month, stepped-wedge, cluster-randomized trial. Every 3 months, a nursing home switched from care as usual to the use of the intervention.InterventionThe 3-month MoSART+ intervention involved ambassador training, staff performing sound measurements with the MoSART application, meetings, and implementation of microinterventions. The goal was to raise awareness about soundscapes and their influence on residents.Setting and participantsWe included 110 residents with dementia in 5 Dutch nursing homes. Exclusion criteria were palliative sedation and deafness.MethodsThe primary outcome was NPS severity measured with the Neuropsychiatric Inventory–Nursing Home version (NPI-NH) by the resident’s primary nurse. Secondary outcomes were quality of life (QUALIDEM), psychotropic drug use (ATC), staff workload (workload questionnaire), and staff job satisfaction (Maastricht Questionnaire of Job Satisfaction).ResultsThe mean age of the residents (n = 97) at enrollment was 86.5 ± 6.7 years, and 76 were female (76.8%). The mean NPI-NH score was 17.5 ± 17.3. One nursing home did not implement the intervention because of staff shortages. Intention-to-treat analysis showed a clinically relevant reduction in NPS between the study groups (?8.0, 95% CI –11.7, ?2.6). There was no clear effect on quality of life [odds ratio (OR) 2.8, 95% CI –0.7, 6.3], psychotropic drug use (1.2, 95% CI 0.9, 1.7), staff workload (?0.3, 95% CI –0.3, 0.8), or staff job satisfaction (?0.2, 95% CI –1.2, 0.7).Conclusions and ImplicationsMoSART+ empowered staff to adapt the local soundscape, and the intervention effectively reduced staff-reported levels of NPS in nursing home residents with dementia. Nursing homes should consider implementing interventions to improve the soundscape.     

Withholding or starting antibiotic treatment in patients with dementia and pneumonia: prediction of mortality with physicians' judgment of illness severity and with specific prognostic models.

BACKGROUND: To help decision makers plan treatment, the authors assessed clinical predictors of mortality from nursing home-acquired pneumonia in patients with dementia. METHODS: Pneumonia patients treated without (n = 165) or with antibiotics (n = 541) were enrolled in a prospective cohort study in 61 nursing homes. RESULTS: In both groups, clinical judgment of illness severity was a strong predictor for 1-week mortality. Despite large differences in frailty and mortality (83% in untreated patients and 15% in treated patients), separate multivariable logistic models included similar specific predictors. DISCUSSION: Despite profound differences between the 2 independent groups, predictors for short-term mortality were largely similar. We found that, when combined with physicians' clinical judgment, 3 readily assessed predictors (respiratory rate, fluid intake, and eating dependency) helped predict mortality. Our results, if confirmed in an independent population, can help make decision making about antibiotic treatment of pneumonia in patients with dementia more evidence-based.     

Prevalence of the dementia syndrome in the oldest residents of a somatic nursing home]

OBJECTIVE. To estimate the prevalence of dementia among subjects of 85 years and over residing in a somatic nursing home. DESIGN. A two-phase design with the mini-mental state examination (MMSE) in the screening phase and the geriatric mental state schedule (GMS) in the diagnostic phase. SETTING. Three somatic nursing homes in Leiden. SUBJECTS. All subjects aged 85 years and over residing in one of the three nursing homes on December 1, 1986. First phase participation rate was 75%; second phase participation rate was 88%. MAIN OUTCOME MEASURE. DSM-III diagnosis of dementia without further specification of the aetiology of the dementia. RESULTS. An overall prevalence of 54% (95% CI: 43-66%) was found. This included 32% mild dementia, 9% moderate and 13% severe dementia. CONCLUSION. Dementia was found to be the most prevalent disorder among somatic nursing home residents aged 85 years and over. The shortage of psychogeriatric nursing home beds may have contributed to this high prevalence of dementia. However, the relatively large number of mild cases, which are usually not listed for admission to a psychogeriatric nursing home, indicates that the combination of a beginning dementia with physical impairment led to admission to a somatic nursing home. Considering the growth of the oldest part of the population it is to be expected that the prevalence of dementia will remain high among the oldest residents of somatic nursing homes.     

Vaccination against influenza in nursing homes in Brussels]

The aims is to measure the immunization rate against influenza in nursing homes in Brussels, to identify the methodologic problems of a survey in this type of population, to analyse the predictors of vaccine administration and to make recommendations for increasing vaccine coverage. On February 1, 1989, there were 339 nursing homes (14,095 beds) in Brussels. These nursing homes were stratified according to their size and administrative status. One home in eight was selected at random as well as two residents in three in each home. The study population included 1,165 residents in 44 nursing homes; their mean age was 81 years. The determinants of vaccine administration were analysed by logistic regression according to Donabedian's model of supply and demand. Vaccine coverage was estimated at 69%; an optimistic estimate since 20 of the homes contacted refused to participate and there are reasons to believe that the immunization rate was low in this group. Among the 781 residents able to respond, only 10% had requested to be immunized. The vaccine had been offered to 67% of that group. Factors predicting vaccine administration were the legal status of the nursing homes, the ambulatory status of the resident, knowledge of the vaccine, a history of prior vaccination, a favorable opinion about the vaccine effectiveness, safety and usefulness. Neither age nor the existence of a chronic condition were significant predictors.     

Three-year prevalence of healthcare-associated infections in Dutch nursing homes

From November 2007 for a period of three years (2007-2009), we conducted an annual one-day prevalence study of healthcare-associated infections (HAIs) among nursing home residents in the Nijmegen region of The Netherlands. In the absence of national HAI definitions applicable to the nursing home setting, we used modified definitions based on US Centers for Disease Control and Prevention criteria for bloodstream infection, lower respiratory tract infection, bacterial conjunctivitis, and gastroenteritis. For the surveillance of urinary tract infection (UTI), criteria established by the Dutch Association of Elderly Care Physicians were used. Resident characteristics were recorded and data collection was performed by the attending elderly care physicians. For the three-year period, 1275, 1323, and 1772 nursing home residents were included, resulting in a prevalence of HAIs of 6.7%, 7.6% and 7.6%, in 2007, 2008 and 2009, respectively. The demographics with respect to age (mean 81 years) and sex (31% men, 69% women) were almost identical in all three years. UTI was the most prevalent HAI with 3.5%, 4.2%, and 4.1% respectively. Most HAIs occurred among residents of rehabilitation units. The prevalence of HAIs varied by nursing home (range: 0.0-32.4%). We present the results of the first prevalence study of HAIs in Dutch nursing homes. Point prevalence studies of HAIs, as part of a quality improvement cycle, are an important cornerstone of infection control programmes in nursing homes, allowing us to further increase patient safety efforts in this setting.     

Neither Race nor Ethnicity Impact the Mortality of Residents of Veterans Affairs Community Living Center With COVID-19

ObjectivesCOVID-19 disproportionately affected nursing home residents and people from racial and ethnic minorities in the United States. Nursing homes in the Veterans Affairs (VA) system, termed Community Living Centers (CLCs), belong to a national managed care system. In the period prior to the availability of vaccines, we examined whether residents from racial and ethnic minorities experienced disparities in COVID-19 related mortality.DesignRetrospective cohort study.Setting and ParticipantsResidents at 134 VA CLCs from April 14 to December 10, 2020.MethodsWe used the VA Corporate Data Warehouse to identify VA CLC residents with a positive SARS-CoV-2 polymerase chain reaction test during or 2 days prior to their admission and without a prior case of COVID-19. We assessed age, self-reported race/ethnicity, frailty, chronic medical conditions, Charlson comorbidity index, the annual quarter of the infection, and all-cause 30-day mortality. We estimated odds ratios and 95% confidence intervals of all-cause 30-day mortality using a mixed-effects multivariable logistic regression model.ResultsDuring the study period, 1133 CLC residents had an index positive SARS-CoV-2 test. Mortality at 30 days was 23% for White non-Hispanic residents, 15% for Black non-Hispanic residents, 10% for Hispanic residents, and 16% for other residents. Factors associated with increased 30-day mortality were age ≥70 years, Charlson comorbidity index ≥6, and a positive SARS-CoV-2 test between April 14 and June 30, 2020. Frailty, Black race, and Hispanic ethnicity were not independently associated with an increased risk of 30-day mortality.Conclusions and ImplicationsAmong a national cohort of VA CLC residents with COVID-19, neither Black race nor Hispanic ethnicity had a negative impact on survival. Further research is needed to determine factors within the VA health care system that mitigate the influence of systemic racism on COVID-19 outcomes in US nursing homes.     

A five-year study of residents of a special hostel for people with dementia

Abstract: In order to consider whether admission to a special hostel was a desirable policy in view of the likelihood of subsequent transfer to a nursing home, this study compared the time spent by residents in a special hostel with the period in a nursing home after they were transferred out of the hostel. We also estimated the number of nursing home places necessary for residents who were transferred and studied the reasons for transfer. The setting was a special hostel in Perth, Western Australia, for 36 people with moderate or severe dementia. The periods spent in the hostel or a nursing home were calculated for all residents admitted between 1985 and 1990. Forty-two of the 84 residents admitted during the study period were transferred to nursing homes. About two thirds of the total time in the two institutions was spent in the hostel. The two principal reasons necessitating transfer to a nursing home were advancing dementia and the addition of a physical impairment. Because a major proportion of the care of selected people with dementia (who can no longer remain at home) can be undertaken in a special hostel, this facility should be included with standard hostel and nursing home in arrangements for institutional care. Between 20 and 25 nursing home places are necessary for residents transferred from a hostel of this size.     

Survival in a cohort of social services placements in nursing and residential homes: factors associated with life expectancy and mortality

The aim of this study was to examine the life expectancy of elderly people in nursing and residential care over a 20-month period and its relationship to specific risk factors. Using a retrospective cohort design, data obtained on 1888 residents placed between 1 July 1997 and 30 April 1999 in residential, nursing and dual registered homes within Nottingham Health Authority boundaries were examined. Additional data on physical and mental disability at placement were available for 514 residents. Main outcome measures comprised survival rate overall, and in relation to gender, age, home type (nursing, residential or dual), source of placement (hospital or community) and various disability factors.One-year survival rates were: overall, 66%; nursing homes, 59%; dual homes, 58%; and residential homes 76%. Median survival in nursing homes was 541 days, but was not reached in residential homes. Male gender, admission to nursing or dual registered homes, placement from hospital, decreased mobility and increased age were associated with decreased life expectancy. Although no association was found between length of survival and level of cognitive function, lack of cognitive impairment was associated with lower survival. In conclusion, mortality is high in nursing, dual and residential homes where life expectancy has been shown to be associated with gender, home type, origin of placement and mobility. Rates of survival are related to higher comorbidity and disability. Important data for planning and assessing care needs can be yielded through the analysis of mortality data.     

Clinical findings associated with radiographic pneumonia in nursing home residents.

OBJECTIVE: Subtle presentation and the frequent lack of on-site physicians complicate the diagnosis of pneumonia in nursing home residents. We sought to identify clinical findings (signs, symptoms, and simple laboratory studies) associated with radiographic pneumonia in sick nursing home residents. STUDY DESIGN: This was a prospective cohort study. POPULATION: The residents of 36 nursing homes in central Missouri and the St. Louis area with signs or symptoms suggesting a lower respiratory infection were included. OUTCOME MEASURED: We compared evaluation findings by project nurses with findings reported from chest radiographs. RESULTS: Among 2334 episodes of illness in 1474 nursing home residents, 45% of the radiograph reports suggested pneumonia (possible=12%; probable or definite = 33%). In 80% of pneumonia episodes, subjects had 3 or fewer respiratory or general symptoms. Eight variables were significant independent predictors of pneumonia (increased pulse, respiratory rate =30, temperature =38 degrees C, somnolence or decreased alertness, presence of acute confusion, lung crackles on auscultation, absence of wheezes, and increased white blood count). A simple score (range = -1 to 8) on the basis of these variables identified 33% of subjects (score > or =3) with more than 50% probability of pneumonia and an additional 24% (score of 2) with 44% probability of pneumonia. CONCLUSIONS: Pneumonia in nursing home residents is usually associated with few symptoms. Nonetheless, a simple clinical prediction rule can identify residents at very high risk of pneumonia. If validated in other studies, physicians could consider treating such residents without obtaining a chest radiograph.     

Impact of nursing home deaths on life expectancy calculations in small areas

STUDY OBJECTIVE: The drive to tackle health inequalities at the local level has increased interest in mortality data for small populations. There is some concern that nursing homes may affect measures of mortality for small populations, but there has been little in depth analysis of this. DESIGN AND SETTING: Deaths between 1997 and 2001 and population figures from the GP register (Exeter) database and census 2001 were used to produce life expectancy (LE) figures for all electoral wards in West Sussex. The proportion of those dying within each ward that had been residents of nursing homes was calculated and the relation between these variables and deprivation investigated. RESULTS: There was a significant linear relation between nursing home deaths and LE (p<0.0001), which explained 36% of variation in LE between wards. Deprivation accounted for around 35% of the variation in LE (p<0.0001) but was not correlated with nursing home deaths (p> or =0.0982). Multiple linear regression shows that over 60% of the variation in LE at ward level can be explained by both nursing home deaths and deprivation (p<0.0001) and that the two variables explain similar proportions of this variation. The relation between LE and nursing home deaths within wards grouped by deprivation suggests that the impact of nursing homes is strongest in deprived wards. CONCLUSIONS: This finding has important implications for LE calculations in small populations. Further investigation is now needed to examine the impact of nursing homes in other areas, on other mortality measures, and in larger populations.     

A Randomized Controlled Trial of a Digital Adaptation of the WHELD Person-Centered Nursing Home Training Program

ObjectiveDigital approaches to delivering person-centered care training to nursing home staff have the potential to enable widespread affordable implementation, but there is very limited evidence and no randomized controlled trials (RCTs) evaluating digital training in the nursing home setting. The objective was to evaluate a digital person-centered care training intervention in a robust RCT.DesignWe conducted a 2-month cluster RCT in 16 nursing homes in the United Kingdom, randomized equally to receive a digitally adapted version of the WHELD person-centered care home training program with virtual coaching compared to the digital training program alone.Setting and ParticipantsThe study was conducted in UK nursing homes. There were 175 participants (45 nursing home staff and 130 residents with dementia).MethodsThe key outcomes were the well-being and quality of life (QoL) of residents with dementia and the attitudes and knowledge of nursing home staff.ResultsThere were significant benefits in well-being (t = 2.76, P = .007) and engagement in positive activities (t = 2.34, P = .02) for residents with dementia and in attitudes (t = 3.49, P = .001), including hope (t = 2.62, P = .013) and personhood (t = 2.26, P = .029), for staff in the group receiving digital eWHELD with virtual coaching compared to the group receiving digital learning alone. There was no improvement in staff knowledge about dementia.Conclusion and ImplicationsThe study provides encouraging initial clinical trial evidence that a digital version of the WHELD program supported by virtual coaching confers significant benefits for care staff and residents with dementia. Evidence-based digital interventions with remote coaching may also have particular utility in supporting institutional recovery of nursing homes from the COVID-19 pandemic.     

Admission of nursing home residents to a hospital internal medicine department

ObjectiveHospitalization of nursing home residents is costly and potentially exposes residents to iatrogenic disease and psychological harm.Design and SettingIn this study, we analyzed the data from the Basic Minimum Data Set of patients hospitalized from the nursing home who were discharged from all the internal medicine departments at the National Health Service hospitals in Spain between 2005 and 2008, according to the data provided by the Ministry of Health and Consumer Affairs.ResultsBetween January 2005 and December 2008, 2,134,363 patients were admitted to internal medicine departments in Spain, of whom 45,757 (2.1%) were nursing home residents. Overall, 7898 (17.3%) patients died during hospitalization, 2442 (30.91%) of them in the first 48 hours. The following variables were the significant predictors of in-hospital mortality in multivariate analysis: age (odds ratio [OR] 1.02, 95% confidence intervals [CI] 1.02–1.03), female gender (OR 1.13, 95% CI 1.13–1.17), dementia (OR 1.09, 95% CI 1.03–1.16), previous feeding tube (OR 1.34, 95% CI 1.09–1.79), malignant disease (OR 2.03, 95% CI 1.86–2.23), acute infectious disease (OR 1.18, 95% CI 1.12–1.25), pressure sores (OR 1.88, 95% CI 1.62–1.95), acute respiratory failure (OR 2.00, 95% CI 1.90–2.10), and nosocomial pneumonia (OR 2.5, 95% CI 2.23–2.72).ConclusionsTwo of every 100 patients admitted to internal medicine departments came from nursing homes. The rate of mortality is very high in these patients, with almost one third of patients dying in the first 48 hours, which suggests that many of these transfers were unnecessary. The cost of these admissions for 1 year was equivalent to the annual budget of a 300- to 400-bed public hospital in Spain. The mechanism of coordination between nursing homes and public hospitals must be reviewed with the aim of containing costs and facilitating the care of patients in the last days of life.     

Discharge planning in nursing homes.

OBJECTIVE. The purpose of this study is to identify nursing home residents who vary in their discharge planning needs. DATA SOURCES AND STUDY SETTING. Administrative records from a database maintained by the National Health Corporation were the primary data source. The 3,883 persons studied were admitted in 1982 to one of 48 nursing homes located in Tennessee, other southern states, and Missouri. STUDY DESIGN. Residents were followed until discharge or for one year, whichever occurred first. A multinomial logistic regression model was used to identify the characteristics at the time of admission of persons likely to go home and the characteristics of those who may be able to be discharged to other residential care facilities. DATA EXTRACTION METHODS. A data tape with resident information was supplied by the National Health Corporation, which also provided data on the 48 nursing homes. Market data were obtained from the Area Resource File. PRINCIPAL FINDINGS. Health status measures are important predictors of discharge status. Financial status (i.e., primary payer) also had a large effect on discharge status; a measure of potential informal care in the community did not. CONCLUSIONS. It is possible to identify at admission nursing home residents likely to have very different discharge planning needs. Nursing home staff can use the results to focus their discharge planning efforts. Regulators can use them to assess how well nursing homes are meeting the discharge planning needs of their residents.